Background: Social prescribing is a way of addressing the 'non-medical' needs (e.g. loneliness, debt, housing problems) that can affect people's health and well-being. Connector schemes (e.g. delivered by care navigators or link workers) have become a key component to social prescribing's delivery. Those in this role support patients by either (a) signposting them to relevant local assets (e.g. groups, organisations, charities, activities, events) or (b) taking time to assist them in identifying and prioritising their 'non-medical' needs and connecting them to relevant local assets. To understand how such connector schemes work, for whom, why and in what circumstances, we conducted a realist review. Method: A search of electronic databases was supplemented with Google alerts and reference checking to locate grey literature. In addition, we sent a Freedom of Information request to all Clinical Commissioning Groups in England to identify any further evaluations of social prescribing connector schemes. Included studies were from the UK and focused on connector schemes for adult patients (18+ years) related to primary care. Results: Our searches resulted in 118 included documents, from which data were extracted to produce contextmechanism-outcome configurations (CMOCs). These CMOCs underpinned our emerging programme theory that centred on the essential role of 'buy-in' and connections. This was refined further by turning to existing theories on (a) social capital and (b) patient activation. Conclusion: Our realist review highlights how connector roles, especially link workers, represent a vehicle for accruing social capital (e.g. trust, sense of belonging, practical support). We propose that this then gives patients the confidence, motivation, connections, knowledge and skills to manage their own well-being, thereby reducing their reliance on GPs. We also emphasise within the programme theory situations that could result in unintended consequences (e.g. increased demand on GPs).

BackgroundWe conducted a randomized controlled trial of a digital health system supporting clinical care through monitoring and self-management support in community-based patients with moderate to very severe chronic obstructive pulmonary disease (COPD).ObjectiveThe aim of this study was to determine the efficacy of a fully automated Internet-linked, tablet computer-based system of monitoring and self-management support (EDGE‚ sElf-management anD support proGrammE) in improving quality of life and clinical outcomes.MethodsWe compared daily use of EDGE with usual care for 12 months. The primary outcome was COPD-specific health status measured with the St George’s Respiratory Questionnaire for COPD (SGRQ-C).ResultsA total of 166 patients were randomized (110 EDGE, 56 usual care). All patients were included in an intention to treat analysis. The estimated difference in SGRQ-C at 12 months (EDGE−usual care) was −1.7 with a 95% CI of −6.6 to 3.2 (P=.49). The relative risk of hospital admission for EDGE was 0.83 (0.56-1.24, P=.37) compared with usual care. Generic health status (EQ-5D, EuroQol 5-Dimension Questionnaire) between the groups differed significantly with better health status for the EDGE group (0.076, 95% CI 0.008-0.14, P=.03). The median number of visits to general practitioners for EDGE versus usual care were 4 versus 5.5 (P=.06) and to practice nurses were 1.5 versus 2.5 (P=.03), respectively.ConclusionsThe EDGE clinical trial does not provide evidence for an effect on COPD-specific health status in comparison with usual care, despite uptake of the intervention. However, there appears to be an overall benefit in generic health status; and the effect sizes for improved depression score, reductions in hospital admissions, and general practice visits warrants further evaluation and could make an important contribution to supporting people with COPD.Trial registrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 40367841; http://www.isrctn.com/ISRCTN40367841 (Archived by WebCite at http://www.webcitation.org/6pmfIJ9KK)

The mHealth applicationThe EDGE (sElf-management anD support proGrammE) COPD project aims to evaluate the efficacy of a multi-component mHealth intervention, delivered via a tablet computer, to improve quality of life in patients with COPD.12 This mHealth intervention focused on simplicity of use (touch screen, no keyboard), and consisted of a symptom diary (Figure 1), 13 remote self-monitoring (pulse oximetry) (Figure 2), and multimedia educational and self-management materials (videos, text, and images).Patients were asked to complete the symptom diary and pulse oximetry daily to understand individual variability. These data were reviewed at regular intervals (but not daily) by a respiratory research nurse, but patients were aware that they would have Abstract BackgroundTelehealth shows promise for supporting patients in managing their long-term health conditions, such as chronic obstructive pulmonary disease (COPD). However, it is currently unclear how patients, and particularly older people, may benefit from these technological interventions. AimTo explore patients' expectations and experiences of using a mobile telehealth-based (mHealth) application and to determine how such a system may impact on their perceived wellbeing and ability to manage their COPD. Design and settingEmbedded qualitative study using interviews with patients with COPD from various community NHS services: respiratory community nursing service, general practice, and pulmonary rehabilitation. MethodAn embedded qualitative study was conducted to which patients were recruited using purposive sampling to achieve maximum variation. Interviews were carried out prior to receiving the mHealth system and again after a 6-month period. Data were analysed using a grounded theory approach. ResultsThe sample comprised 19 patients (aged 50-85 years) with varied levels of computer skills. Patients identified no difficulties in using the mHealth application. The main themes encapsulating patients' experience of using the mHealth application related to an increased awareness of the variability of their symptoms (onset of exacerbation and recovery time) and reassurance through monitoring (continuity of care). ConclusionPatients were able to use the mHealth application, interpret clinical data, and use these within their self-management approach regardless of previous knowledge. Telehealth interventions can complement current clinical care pathways to support self-management behaviour.

There is limited published research into what really matters to people living with chronic obstructive pulmonary disease (COPD). Most previous research in this area focuses on the impact of the symptoms of COPD, rather than on the issues defined as important by patients themselves. This paper describes an exploratory study investigating what is most important to people living with COPD. A qualitative approach employing in-depth interviews with COPD patients was chosen. Thematic analysis was used to code and categorize data. Six patients with 'moderate' to 'very severe' COPD were recruited. They considered engagement in specific activities to be very important (walking, household maintenance and driving), even though these activities were mainly centred around the home environment, or within confined spaces, due to their physical limitations. This restriction led to feelings of social isolation that these patients tried to overcome through social participation (holidays, social interaction). People with COPD often experience physical restrictions, which can lead to reduced community mobility and social isolation. In this study, despite their physical limitations, these patients had a strong desire to participate and be engaged in various activities. The importance of enabling patients to 'participate' rather than just 'do' should be considered when planning and delivering patient-centred interventions across the whole spectrum of severity of COPD.

BackgroundSelf-management strategies have the potential to support patients with chronic obstructive pulmonary disease (COPD). Telehealth interventions may have a role in delivering this support along with the opportunity to monitor symptoms and physiological variables. This paper reports findings from a six-month, clinical, cohort study of COPD patients’ use of a mobile telehealth based (mHealth) application and how individually determined alerts in oxygen saturation levels, pulse rate and symptoms scores related to patient self-initiated treatment for exacerbations.MethodsThe development of the mHealth intervention involved a patient focus group and multidisciplinary team of researchers, engineers and clinicians. Individual data thresholds to set alerts were determined, and the relationship to exacerbations, defined by the initiation of stand-by medications, was measured. The sample comprised 18 patients (age range of 50–85 years) with varied levels of computer skills.ResultsPatients identified no difficulties in using the mHealth application and used all functions available. 40 % of exacerbations had an alert signal during the three days prior to a patient starting medication. Patients were able to use the mHealth application to support self- management, including monitoring of clinical data. Within three months, 95 % of symptom reporting sessions were completed in less than 100 s.ConclusionsHome based, unassisted, daily use of the mHealth platform is feasible and acceptable to people with COPD for reporting daily symptoms and medicine use, and to measure physiological variables such as pulse rate and oxygen saturation. These findings provide evidence for integrating telehealth interventions with clinical care pathways to support self-management in COPD.

Aim: The aim of this study was to explore, using qualitative research methods, how pulmonary rehabilitation (PR) programmes affect the experience of activity and breathlessness of people with COPD.Methods: A qualitative, interview-based approach was employed. Participants were interviewed pre-and post-PR. Data were analysed using systematic strategies informed by grounded theory methods.Results: Nine participants (three female) took part. A change in participants' perception of breathlessness and lessening of fear of activity were the main themes identified. PR appeared to impact on the experience of physical social activities, allowing participants to overcome feelings of social isolation.Conclusions: Prior to PR, participants associated activities with breathlessness and panic; post PR, participants reported reduced fear and felt able to increase their activities. These findings add to our understanding of the impact of PR on individuals' experience of activity and may contribute to improved programmes by addressing patients' needs.

Study Design Secondary analysis, pre-treatment:post-treatment observational study. Objective: C ompare the reliability and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Knee Outcome Survey-Activities of Daily Living Scale (ADLS), and the Lower Extremity Functional Scale (LEFS) in individuals with knee osteoarthritis (OA). Background The WOMAC is the current standard in patient-reported measures of function in patients with knee OA. The ADLS and LEFS have been designed for potential use in patients with knee OA. If the ADLS and/or LEFS are to be considered viable alternatives to the WOMAC in measuring patient-reported function in individuals with knee OA, then they should have measurement properties that are comparable to the WOMAC. It would also be important to determine whether either of these instruments may be superior to the WOMAC in terms of reliability or responsiveness in this population. Methods Data from 168 subjects with knee OA who participated in a rehabilitation program were used in the analyses. Reliability and responsiveness of each outcome measure were estimated at 2, 6, and 12 month follow-up time points. Reliability was estimated by calculating the intraclass correlation coefficient (2,1) for subjects who were unchanged in status from baseline at each follow-up time point, based on a global rating of change score. To examine responsiveness, the standard error of the measure (SEM), minimum detectable change (MDC), minimum clinically important difference (MCID), and the Guyatt responsiveness index (GRI) were calculated for each outcome measure at each follow-up time point. Results All 3 outcome measures demonstrated reasonable reliability and responsiveness to change. Reliability and responsiveness tended to decrease somewhat with increasing follow up time. There were no substantial differences between outcome measures for reliability or any of the 3 measures of responsiveness at any follow-up time point. Conclusions The results do not indicate that one outcome measure is superior to another with regards to reliability and responsiveness when applied to subjects with knee OA. We believe all 3 instruments are appropriate outcome measures to examine change in functional status of patients with knee OA.

Pulmonary rehabilitation has short-term benefits on dyspnea, exercise capacity and quality of life in COPD, but evidence suggests these do not always translate to increased daily physical activity on a patient level. This is attributed to a limited understanding of the determinants of physical activity maintenance following pulmonary rehabilitation. This systematic review of qualitative research was conducted to understand COPD patients’ perceived facilitators and barriers to physical activity following pulmonary rehabilitation. Electronic databases of published data, non-published data, and trial registers were searched to identify qualitative studies (interviews, focus groups) reporting the facilitators and barriers to physical activity following pulmonary rehabilitation for people with COPD. Thematic synthesis of qualitative data was adopted involving line-by-line coding of the findings of the included studies, development of descriptive themes, and generation of analytical themes. Fourteen studies including 167 COPD patients met the inclusion criteria. Seven sub-themes were identified as influential to physical activity following pulmonary rehabilitation. These included: intentions, self-efficacy, feedback of capabilities and improvements, relationship with health care professionals, peer interaction, opportunities following pulmonary rehabilitation and routine. These encapsulated the facilitators and barriers to physical activity following pulmonary rehabilitation and were identified as sub-themes within the three analytical themes, which were beliefs, social support, and the environment. The findings highlight the challenge of promoting physical activity following pulmonary rehabilitation in COPD and provide complementary evidence to aid evaluations of interventions already attempted in this area, but also adds insight into future development of interventions targeting physical activity maintenance in COPD.